Overcoming the Digital Divide Through Community-Based Telehealth

March 05, 2024 - The unprecedented rise in telehealth use in recent years signified a new era in healthcare delivery that purported to meet patients where they are. Though the much-lauded benefits of telehealth technology are rooted in real-world evidence, the digital divide has stemmed its potential. Thus, healthcare provider organizations are working to expand access to telehealth itself, establishing various initiatives to bring the technology to underserved communities.

The digital divide refers to the gap between communities that have access to modern information and communications technology and those that don't or have restricted access.

A Pew Research Center survey reveals that 80 percent of Americans have access to broadband at home, but access varies across demographics and regions. The survey, conducted from May 19 to September 5, 2023, polled 5,733 United States adults. It shows that Asian and White adults are more likely than Hispanic or Black adults to subscribe to home broadband, and adults living in rural and urban areas are less likely to subscribe to it than those living in suburban areas.

Further, households earning $100,000 or more annually are far more likely to own a smartphone than those earning less than $30,000 per year.

These disparities severely limit access to telehealth in underserved communities. To combat this issue, the University of Rochester Medical Center (URMC) in New York State and Parkland Health in Texas have established telehealth access points in common community spaces.

A NEED FOR COMMUNITY-BASED TELEHEALTH ACCESS

Both URMC and Parkland Health care for large, diverse, and underserved patient populations.

URMC is the largest health system outside New York City and covers a large geographic region of New York State.

“Essentially, the whole western half of the state is part of our market, and because we have such a large geography that we cover, we have a lot of diversity in that geography,” said Michael J. Hasselberg, PhD, chief digital health officer at URMC, in an interview with mHealthIntelligence.

The population encompasses inner-city communities in the city of Rochester, rural and farming communities further out from the city, and the Mennonite and Amish population on the city's outskirts.

Like most health systems, URMC rapidly expanded telehealth services following the onset of the COVID-19 pandemic. The health system examined where telehealth had the biggest impact and found major improvements in adherence to care and no-show and cancellation rates among its Medicaid patient population.

“Those engaged in telehealth actually required less in-person follow-up care and required less high-cost imaging and lab tests in follow-up,” said Hasselberg. “But there was a caveat in our data, and what we had found was actually in our rural communities in particular, our patients were only engaging in audio-only telehealth.”

And it wasn’t because of a lack of broadband infrastructure, he added. The state had significantly invested in building up rural access to broadband internet. It was a more pernicious problem: poverty.

“Patients in these rural communities, which were some of our most impoverished communities, couldn't afford internet access into their home,” Hasselberg said. “And so, the only internet access they had was their data plans through their cellular providers. And video is a very data-intensive feed, and folks didn't want to use up their data plans for video visits, but they all have unlimited talk and text for most of these plans.”

Similarly, Parkland Health’s patient population in Dallas County struggles with challenges stemming from the digital divide. After expanding telehealth services during the pandemic, the health system saw that lack of access to high-speed broadband and devices were major barriers to care access.

“Our patient population, they have smart devices, but some of what we see are older models,” said Molly Case, director of virtual care at Parkland Health, in an interview with mHealthIntelligence. “And as technology continues to improve, the updates and things that have to happen on the phones or tablets or even if they happen to have a laptop at the house or something to that nature, that has to be able to keep up.”

In an effort to circumvent the digital divide plaguing its patient populations, Parkland and URMC turned to community-based telehealth approaches.

EFFORTS TO BRING TELEHEALTH TO UNDERSERVED COMMUNITIES

The growing need for access to telehealth amid the digital healthcare boom of the pandemic drove both Parkland Health and URMC to set up telehealth access points in their communities.

At the end of 2023, Parkland Health established a telehealth pod at a food bank, the Inspired Vision Compassion Center (IVCC), in Dallas. Here, people can access healthcare providers to meet urgent acute care needs as well as primary care services.

Through the pod, people can schedule same-day or next-day telehealth appointments with Parkland physicians and advanced practice providers and attend those appointments. Patients can schedule video visits through their Parkland Health My Chart accounts before coming to the pod or while there.

Case described the structure as about the size of an “old school telephone booth,” with a desk, a chair, and a computer with a webcam and speakers.

“It's intended to be as basic as we could get it,” she said. “We intentionally didn't start with any kind of vital sign machines or anything in there.”

There are no on-site clinical staff at the booth, but a guidebook provides step-by-step instructions for logging in and joining the appointment. There is also an e-support line that patients can use if they need technical assistance.  

The IVCC is in the 75217 ZIP code in Dallas County, an area the health system had identified as having significant health disparities in its 2022 Community Health Needs Assessment. Close to 1,800 people go through the food bank per week, many of whom are also seeking healthcare services, Case noted. The health system already conducts health screenings and provides financial assistance services at the IVCC every week, and the new telehealth booth is expected to complement these resources.

URMC went a different route with its most recent community-based telehealth effort. The health system has partnered with Five Star Bank to set up telehealth stations at some of its locations in Upstate New York.

Though the health system considered other community-based facilities, such as libraries, churches, and barbershops, leaders ultimately decided against these locations as scaling the telehealth access initiative would be challenging.

“Because it takes a lot of resources to negotiate contracts with community centers, libraries, fire stations, barbershops — they're all standalone entities,” said Hasselberg. “And that means as a health system, I have to negotiate with every single barbershop or every single community center to set up these access points.”

The health system even considered partnering with retailers. However, Hasselberg noted that retailers’ primary goal is to sell products, and setting up telehealth access points takes away floor space from their products. The volumes generated in integrated clinics or telehealth hubs within stores are typically insufficient to offset losses from reducing product inventory, he added.

So, URMC examined other viable options for telehealth access points in the communities it serves.

“We were like, well, what is in a rural community?” he said. “You've got a main street, and there's a traffic light, and there's usually a dollar store, and there's a bank. We kind of thought, well, what about banks?”

Working with a bank proved to be a good fit for this initiative for multiple reasons. First, telehealth access points within banks are scalable. Once negotiations with the main bank branch are completed, access points can be set up in the bank’s satellite locations as well, Hasselberg said.

Second, rural banks are trying to reinvent themselves to survive the digital transformation of the banking industry.

“They've got space that is not being used because of their digital transformation. They're a trusted institution in these communities. I don't have to worry about a product because they're not selling a product,” Hasselberg said.

So, URMC struck a partnership with Five Star Bank to establish telehealth stations in three branch locations. This pilot initiative also includes two companies, DexCare and Higi, which provide the technological resources for the stations.

DexCare provides an on-demand telehealth platform connecting users to URMC clinicians, offering primary, pediatric, and urgent care services. Higi provides biometric monitoring kiosks, which enable health indicator measurements such as blood pressure and weight.

With these technologies, Western New York residents can walk into one of the three Five Star Bank locations involved in the pilot for a telehealth visit and have their vitals monitored at the same time.

“Essentially, you can use [the telehealth stations] for on-demand video visits for primary urgent care needs right now, or you can use it for preventative care and chronic disease monitoring from a biometric standpoint,” Hasselberg explained.

DEPLOYMENT STRATEGIES AND LESSONS LEARNED

Implementing community-based telehealth access initiatives is no easy lift, with both health systems considering a wide array of factors to ensure success.

For URMC, the most challenging aspects of implementation were establishing operational workflows and encouraging behavioral change, according to Hasselberg. Not only did the health system’s clinical care teams create infection prevention workflows to accommodate sick people entering bank locations, but they also gathered insights from all stakeholders — the patients, bank staff, and primary care physicians — to develop strategies for prompting behavioral change.

“I mean, the whole concept of going to get healthcare in a bank, it's just novel,” Hasselberg noted. “People don't think that way. And so, we have a whole kind of community outreach and marketing team from all of those institutions doing marketing to introduce this concept and get community champions to buy in and influencers in those communities to help get the word out that this new offering is there.”

Another critical aspect of deployment was ensuring privacy for the telehealth visits. URMC’s clinical teams set the privacy requirement threshold, following which the bank branches built out rooms or cleared out existing rooms, adding privacy glass and soundproofing where necessary.

Ensuring privacy was also a top priority for Parkland Health as it set up its telehealth pod at IVCC.

“The privacy is very limited in the space,” Case said. “We could [have just] put cubicle walls up, but the noise and volume and everything was going to be coming over that wall fairly easily, and we just didn't feel like it was appropriate, and there could be infringements on [patient] privacy.”

Thus, the pod has a frosted film on the front door to ensure privacy, and while it is not fully soundproofed, the sound is muffled to ensure HIPAA compliance. However, the health system had to be careful to ensure enough sound could come through the door if someone was in trouble and calling out for help.

Additionally, the health system carefully considered the size of the booth. Making it too big could impact Parkland’s ability to establish similar booths in other facilities, but making it too small could make the patient experience uncomfortable, Case explained.

Small details, like making sure that MyChart populates instantly on the computer screen so that users don’t have to look for it, were also added to enhance the patient experience.

Both Parkland and URMC are eager for patient feedback on their newly launched resources.

“We hope that if [Dallas County residents] go in and utilize [the telehealth pod] and they have a great experience, they let us know,” Case said. “If they don't have a great experience, I'm interested in that feedback too because that helps us advance the program; it helps us make changes.”

Hasselberg echoed this sentiment, adding that the six-month pilot phase will help URMC determine the feasibility of implementing telehealth stations in banks. If the pilot succeeds, the health system plans to expand to other Five Star Bank branches and non-bank locations, such as senior living facilities.

Ultimately, the future of these community-based telehealth access points will be determined by the communities themselves.

“This could be essentially a nothing burger, and patients say, ‘I just don't feel comfortable going to a bank to get healthcare,’ but if it does work…this could be really, really transformative,” Hasselberg said.